Pre-Existing Conditions Exclusions

Millions of Americans have pre-existing conditions, which include a broad range of health conditions such as cancer, diabetes, seizures, asthma, allergies and many others.  People with disabilities are more likely than the general population to have pre-existing conditions and are frequently denied (or excluded from) health insurance coverage and/or benefits.

What is a pre-existing condition?

A condition that was present before the date of enrollment for the coverage - whether or not any medical advice, diagnosis, care or treatment was recommended or received.

How does the law change pre-existing conditions exclusions?

Health insurance companies will not be allowed to deny enrollment or specific benefits based on pre-existing conditions for individual under the age of 19. For example, starting on September 23, 2010, insurance companies cannot deny enrollment to a child who needs heart surgery because the heart defect existed before coverage began. In addition, the insurer will not be allowed to deny specific benefits (in this case heart surgery) needed to treat the pre-existing condition.

When will changes to pre-existing conditions exclusions go into effect?

For people under the age of 19, it will go into effect for health insurance plan years that begin on or after September 23, 2010.  For adults (persons 19 an older), it will go into effect for plans beginning on or after January 1, 2014.

Will all plans be affected by the changes to pre-existing conditions exclusions?

No. There is one exception. Individual health insurance plans are exempted. Individual health insurance plans are policies that individuals buy on the open insurance market (they do not include employer sponsored plans).

What if I currently have inadequate individual insurance for my child with a pre-existing condition?

If a family had bought individual coverage for a child with a preexisting condition and the policy had language excluding the costs of treatment for a pre-existing condition, then the family may need to cancel the coverage and purchase a new policy to get around the exemption.  The risk is that the price you pay may be more for the new plan.